Race And The Shocking Inequalities In Pain Management

Race And The Shocking Inequalities In Pain Management

It’s true that race relations in the United States have come a long way since Jim Crow laws created the phrase “separate but equal,” but when it comes to pain management, the U.S. still has a long way to go. Study after study is confirming what many of us already know: minorities receive grossly unequal treatment when it comes to pain management and diagnosis. This is not just theory; research in the past year has demonstrated time and again that if you are black or Hispanic, your pain management may be less than that of a white pain patient.

Minorities less like to receive appropriate pain management

A study from Brigham and Women’s Hospital found that minority patients were 22 to 30% less likely to receive analgesic medication for abdominal pain than white patients. Researchers looked at over 6,700 visits to the emergency room between 2006 and 2010 and found that for the same issue (acute abdominal pain), minority patients were more likely to be undertreated for pain.

Adil Haider, MD, MPH, Kessler Director of the Center for Surgery and Public Health at Brigham and Women’s Hospital and last author of the study, pointed out that these findings were particularly important because not only do they point out institutional bias but that bias exists in institutions that serve the highest proportion of minorities, noting:

“We found that minorities experience significant disparities with regard to the receipt of analgesic medications for abdominal pain; black patients had the greatest increased odds of undertreatment for pain among the groups considered. These findings add to the overwhelming evidence that racial/ethnic disparities not only exist, but are endemic in health care settings. Particularly important is the fact that these differences in pain medication use were concentrated in hospitals that treated the largest percentages of minority patients and among those reporting the severest pain, indicating that hospital-level factors may play an important role in eliminating disparities.”

Racial bias in pain management

A more recent study from the University of Virginia confirmed these findings in a 2016 study that found systemic undertreatment of pain among black people in the U.S. This bias in pain management may be linked to the fact that white people in the U.S. are over-prescribed (and under-utilize) pain medications, while black people are under-prescribed analgesics for pain relative to not only white people but also general pain management guidelines from the World Health Organization.

Researchers attribute this to racial bias among hospital workers. In a survey of 222 white medical students and residents, researchers asked several questions about whether or not the students and residents believed the following false statements were true:

Blacks age more slowly than whites

The nerve endings of black people are less sensitive than white people

Black people’s blood clots faster than white people’s

Black people have thicker skin than white people

Students and residents were also asked to rate the pain of a kidney stone and a broken leg for a white and black patient and to prescribe pain management for each patient based on the students’ and residents’ perceived level of each pain for both patients.

Of the false statements, half of the students and residents believed at least one of the false statements was true. These same students and residents gave less accurate pain management recommendations for black patients versus white patients based also on an inaccurate perception of their pain.

Kelly Hoffman, a UVA psychology Ph.D. candidate who led the study, points out that many of these false beliefs are the same beliefs that were present during slavery in the U.S, and are still dangerous today, noting:

“We’ve known for a long time that there are huge disparities in how blacks and whites are assessed and treated by the medical community. Our study provides some insight to what might contribute to this — false beliefs about biological differences between blacks and whites. These beliefs have been around for a long time in our history. They were once used to justify slavery and the inhumane treatment of black people in medicine. What’s so striking is that, today, these beliefs are not necessarily related to individual prejudice. Many people who reject stereotyping and prejudice nonetheless believe in these biological differences. And these beliefs could be really harmful; this study suggests that they could be contributing to racial disparities.”

A study of children admitted to the emergency room with appendicitis found similar racial bias. White children were more likely than black children to receive pain medication for any kind of pain. White children were also more likely to be treated for severe pain with opioids. In the U.S., racial bias in pain management starts young.

Racial bias in obtaining healthcare

Forget about treatment in an emergency room – what about getting healthcare of any kind? A study out of the University of Oregon found that Latinos in rural areas experienced discrimination when they attempted to obtain health services. This discrimination may play a role in generally poor outcomes experienced by Latinos when it comes to all types of diseases, including heart disease and diabetes.

Of the 349 Latinos aged 18 to 25 interviewed for the study, 40% said they felt discrimination when they attempted to obtain health services, including being harassed or made to feel inferior. This may be the main reason why Latinos are an underserved group in the U.S. when it comes to healthcare. The study found that many Latinos have the perception of disrespect coming from the healthcare establishment, enough so that it is considered a barrier to treatment.

Monoracial bias in pain management and healthcare in general

Patients who switch the reporting of their racial identity from a single race to a multiracial status find the opposite to be true: multiracial people are more likely to experience better outcomes and better health over time than their monoracial peers.

While this may be attributed to bias, part of this is simply practical. A multiracial person may be screened more actively for conditions affecting both races (e.g., a black person who is an Ashkenazi Jew may be screened more aggressively for a prominent breast cancer gene than a person who simply identifies as black).

Karen M. Tabb Dina, social work professor and lead author of two studies examining the impact of racial identity on healthcare, believes that these limitations (only being able to code in one race) are serious and pose a significant threat to health, noting:

“By recoding race, we’re probably masking the actual health patterns that we need to uncover. We’re not tapping into these patterns and not thinking creatively on how we can address racial and ethnic health disparities. Looking carefully at how people identify themselves can give us more insight into what the underlying problems are and how they differ across racial and ethnic groups.”